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Exemption Application FORM <br /> With Your County For a Qualifying For-Profit Nursing Facility, Skilled Nursing Facility,or <br /> Assessor on or Assisted-Living Facility 451 <br /> 1NF <br /> Before December 31 Annual Film Required <br /> — — -- — <br /> Name of Owner County Name I Tax Year <br /> GRAND ISLAND HEALTH CARE INC HALL COUNTY 2026 <br /> Name of Business i1 Different than Owner <br /> TIFFANY SQUARE <br /> Street or Other Mailing Address of Applicant ' City State Zip Code <br /> 20220 HARNEY STREET ELKHORN 1NE 68022 <br /> Contact Name I Email Address f Phone Number Parcel Number <br /> BRIANSTUHR BSTUHR©VHSMAIL.COM [402-895-3932 0400295849 <br /> Legal Description of Real Property <br /> WEBB ROAD SUB PT LT 4 S-T-R; 01-11-9 3119 FAIDLEY AVE, GRAND ISLAND, NE <br /> What type of for-profit facility is the exemption being applied?(check all that apply) 0^.-+t, <br /> For more information on g. <br /> exemptions, 4"'"` <br /> Nursing Facility Skilled Nursing Facility ❑Assisted-Living Facility permissiveP i''' <br /> please scan the OR code. , 0. <br /> o <br /> Does this facility accept Medicaid benefits? X Yes C No <br /> If yes.complete the information below for the most recent three-year period from date the form is completed: <br /> The exemption percentage for each year in the most recent three-year period is equal to a facility's number of occupied Medicaid beds for a given year divide by the facility's total number <br /> of occupied bed for that year.The exemption percentage for each year is added together and divided by three to calculate the average percentage of occupied Medicaid beds over the <br /> most recent three year period.This number is the final exemption percentage that will be multiplied by the facility's property taxes to determine the facility's exemption amount.Please see <br /> specific instructions on reverse side for each column below. <br /> 1 1 2 I 3 4 <br /> The three most recent Total number of Total number of Percentage of occupied <br /> years: occupied beds for year occupied Medicaid Medicaid Beds: <br /> specified in Column(1) Beds for Year Column(3)divided by Column(2) <br /> Year 1:202 5 21004 10396 49% <br /> Year 2:2024 27616 13059 47% <br /> Year 3:2023 29930 11709 I 39% <br /> 5 5a 5b <br /> Calculate the three year Sum of three year Average Occupied <br /> average percentage of Percentages from Medicaid Beds <br /> occupied Medicaid beds Column(4) Percentage Column DEC 12 2025 <br /> for exempt purposes (5a)divided by 3 <br /> o HALL°DUN IY ASSESSOR <br /> 135 I 45/o GRAND ISLAND, NEBRASKA <br /> Under penalties of law.I declare at I ve xamined this exemption application and.to the best of my knowledge and belief,it is correct and complete. <br /> I also decl at I am duly a on d t sign this exemption application. <br /> sign caaVrk*Cr <br /> ia' /O�000� <br /> h,n <br /> e ' Authorized Signatu e <br /> e Date <br /> Retain a copy for your records. <br /> For County Assessor's Recommendation <br /> [II Approval for _.f COMMENTS. <br /> ri Denied <br /> 0 Signature of County Assessor Date <br /> I I For County Board of Equalization Use Only I <br /> r Approved for _% It the County Board's determination is different from the County Assessor's recommendation,an explanation is required. <br /> Denied <br /> 4 <br /> 7 ' <br /> Sign•tune of County/oar/der • e <br /> County Clerk:A legible copy of this for ' showing the final decision of the County Board of Equalization <br /> must be delivered electronically to the Nebraska Department of Revenue within seven days after the Board's decision. <br /> Nehraske Department o'Revenue,Property Assessment Division Authorized by Nob.Rev.Stat §f 77.202 <br /> 96 347-2024 Rev.12-2024 <br />